Original Article
Rev. Latino-Am. Enfermagem 2017;25:e2887 DOI: 10.1590/1518-8345.1528.2887
www.eerp.usp.br/rlae
Microbiological testing of devices used in maintaining peripheral venous catheters1 Fernanda de Paula Rossini2 Denise de Andrade3 Lissandra Chaves de Sousa Santos4 Adriano Menis Ferreira5 Caroline Tieppo6 Evandro Watanabe7
Objective: to evaluate the use of peripheral venous catheters based on microbiological analysis of devices (dressing and three-way stopcocks) and thus contribute to the prevention and infection control. Methods: this was a prospective study of microbiological analysis of 30 three-way stopcocks (external surfaces and lumens) and 30 dressing used in maintaining the peripheral venous catheters of hospitalized adult patients. Results: all external surfaces, 40% of lumens, and 86.7% of dressing presented bacterial growth. The main species isolated in the lumen were 50% coagulase-negative Staphylococcus, 14.3% Staphylococcus aureus, and 14.3% Pseudomonas aeruginosa. Fifty nine percent of multidrug-resistant bacteria were isolated of the three-way stopcocks, 42% of the lumens, and 44% of the dressing with a predominance of coagulase-negative Staphylococcus resistant to methicillin. Besides, 18% gram-negative bacteria with resistance to carbapenems were identified from multidrug-resistant bacteria on the external surfaces of the three-way stopcocks. Conclusion: it is important to emphasize the isolation of coagulase-negative Staphylococcus and gram-negative bacteria resistant to methicillin and carbapenems in samples of devices, respectively, which reinforces the importance of nursing care in the maintenance of the biologically safe environment as well as prevention and infection control practices. Descriptors: Cross Infection; Vascular Access Devices; Catheters; Contamination; Bacteria; Drug Resistance, Microbial.
1
Paper extracted from Doctoral Dissertation “Residence time of the peripheral venous catheter and the bacterial growth in catheter and connector: subsidies for prevention of adverse events”, presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
2
PhD, RN, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
3
PhD, Associate Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
4
Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
5 6
PhD, Associate Professor, Universidade Federal do Mato Grosso do Sul, Três Lagoas, MS, Brazil.
Pharmacy-Biochemistry, Hospital Regional do Mato Grosso do Sul, Campo Grande, MS, Brasil.
7
PhD, Professor, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil.
How to cite this article Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E. Microbiological testing of devices used in maintaining peripheral venous catheters. Rev. Latino-Am. Enfermagem. 2017;25:e2887. [Access ___ __ ____]; Available in: ____________________. DOI: http://dx.doi.org/10.1590/1518-8345.1528.2887. URL
month day year
2
Rev. Latino-Am. Enfermagem 2017;25:e2887.
Introduction
3WSCs) used in peripheral venous access and thus, contribute to the prevention and control of infection.
Health
care
in
the
hospital
environment
is
constantly challenged by infections, which result in
Methods
increases in morbidity and mortality, length of stay, and costs, especially considering the consumption of antibiotics and laboratory tests. Given the proportions, these infections represent one of the largest public health problems, which is aggravated by the presence of resistant strains, since they challenge scientific and
technological
advances
the
attention
professionals,
of
and
therefore
catch
researchers,
and
organizations looking for effective prevention and
This is a microbiological clinical study done on the 3WSCs and dressing used in the maintenance of peripheral venous catheters (PVC) type abbocath used in hospitalized patients. Samples from the devices were collected for adult patients admitted to the medical and neurological clinical
specialty
of
a
public
university
hospital
inpatient for highly complex clinical emergency care. For 60 devices (30 dressing and 30 3WSCs), 90
control measures(1-3). Risk factors for infection is an indicator that deserves careful analysis and elucidation in the management of aseptic techniques. This analysis represents a challenge, given variability of risks and diversity of behaviors and recommendations. In this sense, the need emerges to objectively identify the possible risks of contamination
microbiological processes were carried out, 30 from the external surfaces, 30 from the lumens of the 3WSCs, and 30 from the dressing. The devices analyzed were collected after discontinuing use of the intravenous devices (due to doctor’s orders, obstruction, infiltration, the presence of classic phlebitis signs of pain, edema, hyperthermia, and local hyperemia), or in cases where
and colonization(4-5). The use of intravascular catheters constitutes a vital strategy for clinical practice and effectiveness of treatments(6-8). It is worth mentioning that peripheral venipuncture is not free of complications, since it is an invasive procedure of high frequency done most of the time in a hospital setting, which is a place that presents risks of contamination and colonization, and which requires appropriate conduct in care of catheters. The maintenance of peripheral venous catheters is a complex topic and requires following a number of technical aseptic conformities and operational principles with a view toward safety and the prevention and control
there was a need to change the dressing of the access considering the conditions of integrity and humidity. The removal of these devices from the patients was done exclusively by nurses working in the unit. We believe that removal according to hospital routine preserved the microbiological conditions of the real situation of hospital care. Any type of contamination was avoided during the removal and transfer of the samples to their sterile packaging. The area of the dressing in contact with the catheter insertion site was marked externally to show where the microbiological collection should be made. Furthermore, information was collected as to the
of infection. The incidence of phlebitis and infections associated
date of the peripheral venipuncture that was on the
with peripheral venous catheters is relatively low, but
dressing and description of the general conditions in
the possibility of underestimation of data should be
terms of dirtiness or presence of blood (evaluation of
pointed out, especially considering the high frequency
the macroscopic condition of the dressing). The research
with which this procedure is done in daily routine health
was conducted with the approval of the Research Ethic
care.
Committee (37194214.1.0000.5393).
Catheter-related
bacterial
infections
prolong
hospitalization and increase the cost of treatment, besides presenting attributable mortality rates in the range between 10% to 25%(6,9).
Inclusion criteria The evaluation included 3WSCs used in maintaining
According to these questions: Is it possible to
the PVC and sterile dressing made of soft fabric backed
isolate bacteria from samples of devices (dressing and
with rayon and polyester with hypoallergenic acrylate
three-way stopcocks - 3WSCs) used in peripheral venous
adhesive, water-resistant, non-owcclusive, and made of
access? What is the prevalence and sensitivity profile
hypoallergenic transparent film with vapor permeability.
of the isolated bacteria? Moreover, are these bacteria resistant to carbapenems?
Microbiological processing
Therefore, this research attempts to evaluate the
The collection of biological material from the
microbiological conditions of devices (dressing and
dressing was done by friction on the inner surface www.eerp.usp.br/rlae
3
Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E. with a swab moistened with saline solution, which was
The length of stay of the PVC ranged from 2 to 8
in contact with the catheter insertion site (previously
days: 36.7% of the samples indicated that the venous
defined area) for 30 seconds and in three directions.
catheterization had been done three days ago (72 hours)
Then the swab was transferred to a sterile test tube
and 26.7% four days ago (96 hours). The mean and
(25 mm x 125 mm) containing 20 mL of Tryptic Soy
median of the length of stay of the PVC was 3.75 days and
Broth (TSB). For the culture from the 3WSCS’s lumen,
three days respectively with a standard deviation of 1.48.
a syringe and sterile gloves were used to carry out a
Additionally, when the presence or absence of
flush of 10 mL of TSB through each of the two routes of
macroscopic dirtiness on the devices was analyzed, such
the 3WSCS into a sterile test tube (25 x 125 mm) with
as the presence of blood with bacterial growth in a TSB
glass beads. For the culture of the external surface the
culture medium, it was observed that 46.6% of these
3WSCS was flushed with the routes closed into a sterile
samples were not considered dirty but had a positive
vial with 200 mL of TSB.
culture for bacterial growth, 28% were considered dirty
After these procedures, homogenization was carried
and showed positive results, 16.7% were considered
out on the samples using an AP-56 tube shaker (Phoenix,
dirty but were not positive, and 7.8% were not
Brazil) during 1 minute and then the samples were
considered dirty and also were not positive.
incubated (Quimis, Brazil) at 37°C for 24 hours up to 14
As for the microbiological evaluation of the devices
days (sterility test). The initial microbiological analyses
(dressing, lumen, and the external surface of the
were performed in a Class II Biological Safety Cabin -
3WSCs), 76 bacteria were isolated from the total of 68
Model Bio Seg 12 (VECO Group, Brazil) in the microbiology
positive samples for bacterial growth with the main ones
laboratory. After incubation, the samples were seeded on
being as follows: coagulase-negative Staphylococcus at
Petri plates (15 x 90 mm) with selective culture media
51.3%, Staphylococcus aureus at 12%, Pseudomonas
(Mannitol, MacConkey, and Cetrimide) and processed in
aeruginosa at 9.2%, and Klebsiella pneumoniae at 9.2%
a VITEK
(Figure 1).
®
2 Compact automated system (Biomérieux,
France) for bacterial identification and sensitivity profile.
Results
samples of the dressing, lumen, and external 3WSCS
Of the total of 90 microbiological analyses, the samples from the lumen of the 3WSCs had growth positive levels of 40% in the TSB culture medium. The samples from the dressing showed 86.7% of contamination and the external surface of the 3WSCs 100% (Table 1).
lumens and external surfaces of the three-way stopcocks used in peripheral venous catheters. Ribeirão Preto, SP, Brazil, 2015 Bacterial Growth
Culture Medium (Tryptic Soy Broth)
multi-resistant microorganisms, respectively. It should be pointed out that in some samples more than one bacterium was isolated. Of the total of resistant microorganisms isolated in the samples of the culture from the dressing, the Staphylococcus resistant to methicillin at 91% and Klebsiella pneumoniae resistant to carbapenems at 9% (Table 2). In the lumen of the 3WSCs (Table 3), the one that
stands
out
the
most
is
coagulase-negative
Staphylococcus resistant to methicillin at 100%.
n
%
26
86.7
samples from the external surface of the 3WSCs (Table 4), the three that stand out the most are coagulase-
Dressing
Present Absent
4
13.3
Three-way stopcocks lumen
Present
12
40.0
Absent
18
60.0
Three-way stopcocks external surfaces
Present
30
100
Absent
0
0
www.eerp.usp.br/rlae
surface, 44%, 35.7%, and 73.3% showed growth of
two that stand out the most are coagulase-negative
Table 1 - Evaluation of bacterial growth on dressing,
Devices
Regarding the evaluation of the profile of sensitivity to antibiotics of the bacteria isolated in the positive
Of the total of resistant bacteria isolated in the
negative Staphylococcus with a 72.7% prevalence, followed by 9% for Staphylococcus aureus resistant to methicillin, and 9% for Klebsiella pneumoniae resistant to carbapenems.
4
Rev. Latino-Am. Enfermagem 2017;25:e2887.
Figure 1 - Evaluation of bacteria distribution in the samples of dressing, lumens and external surfaces of the threeway stopcocks used in peripheral venous catheters. Ribeirão Preto, SP, Brazil, 2015 Table 2 - Evaluation of numerical and percentage distribution of bacteria in dressing used in peripheral venous catheters according to antibiotics sensitivity profile. Ribeirão Preto, SP, Brazil, 2015 Dressing Bacteria
Resistant (n=11)
Sensitive (n=14)
n
%
n
%
10*
91.0
3
21.4
Pseudomonas aeruginosa
0
0
3
21.4
Klebsiella pneumoniae
1
9.0
2
14.3
Staphylococcus aureus
0
0
2
14.3
Enterobacter cloacae
0
0
2
14.3
Proteus mirabilis
0
0
1
7.10
Leuconostoc mesenteroides
0
0
1
7.10
Coagulase-negative Staphylococcus
†
* Methicillin-resistant coagulase-negative Staphylococcus. † Carbapenem-resistant Klebsiella pneumoniae.
Table 3 - Evaluation of numerical and percentage distribution of bacteria in lumens of the three-way stopcocks used in peripheral venous catheters according to antibiotics sensitivity profile. Ribeirão Preto, SP, Brazil, 2015 3WSCs* lumen Bacteria
Resistant (n=5)
Sensitive (n=9)
n
%
n
%
Coagulase-negative Staphylococcus
5*
100
2
22.2
Staphylococcus aureus
0
0
2
22.2
Pseudomonas aeruginosa
0
0
2
22.2
Klebsiella pneumoniae
0
0
1
11.0
Proteus mirabilis
0
0
1
11.0
Enterococcus faecalis
0
0
1
11.0
* Methicillin-resistant coagulase-negative Staphylococcus.
Table 4 - Evaluation of numerical and percentage distribution of bacteria in external surfaces of the three-way stopcocks used in peripheral venous catheters according to antibiotics sensitivity profile. Ribeirão Preto, SP, Brazil, 2015 3WSCs* external surface Resistant (n=22)
Bacteria
Sensitive (n=15)
n
%
n
%
Coagulase-negative Staphylococcus
16*
72.7
3
20.0
Staphylococcus aureus
2*
9.0
3
20.0
(continue...) www.eerp.usp.br/rlae
5
Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E.
Table 4 - (continuation) 3WSCs* external surface Resistant (n=22)
Bacteria
Sensitive (n=15)
n
%
n
%
Klebsiella pneumoniae
2†
9.0
1
6.60
Pseudomonas aeruginosa
1†
4.5
1
6.60
Acinetobacter baumannii
1
4.5
1
6.60
Enterococcus faecalis
0
0
2
13.3
Citrobacter koseri
0
0
1
6.60
Proteus mirabilis
0
0
1
6.60
Providencia stuartii
0
0
1
6.60
Enterococcus faecium
0
0
1
6.60
†
* Methicillin-resistant (coagulase-negative Staphylococcus and Staphylococcus aureus). † Carbapenem-resistant (Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii).
Discussion
Pseudomonas aeruginosa (4.5%), and Acinetobacter baumannii (4.5%). Thus, it is important to emphasize
The use of intravascular catheters is one of the
that
good
aseptic
practices
should
be
carefully
important advances in medicine, but we should not be
adopted and enforced by the professionals who
oblivious to the risks inherent in their use, especially
handle the devices used in the maintenance of the
infectious events. Some factors that increase the risk
venous catheters in order to avoid contamination
of infection are use of the devices, insertion site, length
of the internal lumen and resultant bloodstream
of stay, skin preparation, and type and way of fastening
infections(8,10).
the dressing used(8-10). There is a further concern with
At the center of discussions of infection control in
the 3WSCs, because beyond being useful in peripheral
health services is the behavior of health professionals,
venous infusions, they also belong to the arsenal of
and it is mentioned as an important tool in the
venous extensions.
implementation of safe practices(1,13). But even though
The literature reveals a low risk of infection of the
measures to prevent and control bloodstream infection
bloodstream associated with the use of peripheral venous
are carefully established by guidelines, the reality of
catheters; however, we must consider its high use in
health care points to unsatisfactory levels of compliance
health care, a fact that has been changing this scenario(8).
by health professionals, especially for the practices of
On the other hand, one study(11) demonstrated that the
washing hands (10.7%) and disinfection of hubs and
number of bloodstream infections caused by peripheral
connectors (40.0%) prior to drug administration(10,14).
venous catheters and central venous catheters were
It should be noted that connections such as 3WSCs/
similar, and that the peripheral catheters inserted in the
hubs and infusion equipment are a common gateway
emergency department caused the largest number of
for
episodes.
connectors can result in bacterial contamination of the
microorganisms(15).
Inadequate
disinfection
of
The study evaluated the microbiota, the profile of
inner lumen of the catheter, resulting in the formation
sensitivity of the bacteria isolated from some devices
of biofilm and subsequent bloodstream infection(8).
(dressing, lumens, and external surfaces of the 3WSCS)
On the other hand, we cannot ignore the possibility
used in the maintenance of peripheral venous access,
that contamination of the catheter’s inner lumen may
the duration of use of the device, and the presence of
originate in the migration of bacteria inside the catheter
macroscopic dirtiness.
coming from the patient’s skin and migrating to the
In the study, microbial growth in the cultures from
the
external
of
the
3WSCs
catheter’s tip.
was
We consider the contamination rate in the lumen of
100%. Some investigators have speculated that the
the 3WSCs (40%) to be high and worrisome, especially
surface contamination of the 3WSCS occurs due to
by
environmental exposure, manipulation by nursing
Staphylococcus resistant to methicillin. In general, for
staff, contact with the patient’s microbiota and contact
hospitalized patients undergoing intravenous therapy, the
with the bed linen(8,12). Among the resistant bacterial
devices are frequently manipulated to administer drugs
species isolated from the 3WSCS surfaces, the main
at regular intervals; or as is the case with antibiotics,
ones were gram-negative bacteria with a resistance
every 6 hours; or analgesics and antipyretics in the case
to carbapenems such as Klebsiella pneumoniae (9%),
of pain or fever, among other drugs. This fact reinforces
www.eerp.usp.br/rlae
surfaces
resistant
bacteria
such
as
coagulase-negative
6
Rev. Latino-Am. Enfermagem 2017;25:e2887. the need for professionals to adopt safe practices when
resistant to carbapenems is increasingly frequent
administering drugs, including meticulous hand hygiene.
in episodes of bacteremia in critically ill patients(18).
Thus, we highlight the importance of disinfecting the
Thus, another challenging result involved evaluating
hubs and hand hygiene (HH) before and after handling
multidrug-resistant strains and strains with resistance
the devices, along with other procedures that impede
to
contamination of the lumen on the 3WSCs. So failure to
peripheral venous catheters. For decades, the world
observe aseptic principles contributes to contaminating
has witnessed a proliferation of microbes with antibiotic
the devices.
resistance, which implies the acquisition of genes
carbapenems
in
the
maintenance
devices
of
HH is the simplest and least expensive individual
that determine resistance to the point of becoming
measure to prevent the spread of healthcare-related
refractory to virtually all antibiotics, leaving researchers
infections(6). However, it was not our objective in this
and health professionals in a bleak environment with
study, to determine the frequency of this practice when
no therapeutic options. Undoubtedly, one of the most
handling the device.
important factors involved is the wide use of antibiotics
Furthermore, the lids should be used when closing
in outside of hospitals.
the 3WSCs, which should be strictly maintained in order
Another important point is that in health institutions,
to preserve their sterile condition. However, in the real
the spread of resistant strains is also facilitated by
situation of providing care, actions can be taken that
noncompliance
contaminate the inside of the lids, such as leaving them
as washing hands, use of protective barriers, and
on trays or other surfaces with the inner side facing down
decontamination of equipment, among other practices(19).
with
basic
recommendations
such
and then reusing them, when in reality the 3WSCs lids
Although there is evidence in literature of low risk
should be discarded with every handling of the device
of local infection of the bloodstream associated with
for infusion(10).
peripheral venous catheters, this situation is changing(9).
Furthermore, we observed that 86.7% of the
For this reason, one should not miss the importance of
culture from the dressing in TSB were positive, which
this issue, especially considering its gravity, the etiology
is contrary to our hypothesis. It was speculated that it
of the microbial species, and the main predisposing
would be 100%, since dressing are in direct contact with
factors(20-21). The success of the fight against infection
the patient’s skin and their endogenous microbiota, and
depends not only on accurate diagnosis, but also, and
mainly because the sample is collected at the catheter’s
in the same proportion, on improvement of conditions
insertion(11).
in terms of infrastructure and human resources. As
The risk became alarming when profile of sensitivity
mentioned before, the performance and attitudes of
to antibiotics of the species were analyzed; coagulase-
health professionals is relevant. It is necessary to begin
negative
methicillin
to build an educational system that promotes knowledge,
was at 91% and Klebsiella pneumoniae resistant to
Staphylococcus
resistant
to
skills, and attitudes that are converted into legitimized
carbapenems was at 9%. It should be noted that perhaps
critical and reflective professional practice. Some of
four (13.3%) of the negative cultures were associated
these issues are more acute in countries facing crises
with the technique of swab collection at just one point
in basic conditions of infrastructure, which includes the
(ostium of insertion), duration of use of the dressing,
training of human resources.
humidity control, and best aseptic practices
.
The results of the present study encourage a
(16)
The purpose of the dressing is to protect the
number of reflections, and one is the need to perform
puncture site and minimize the possibility of infection
essential prospective surveillance to prevent and control
through the interface between the surface of the
hospital infections, thus favoring decision-making based
catheter and the skin. The dressing should be replaced
on situations of real care.
immediately if contamination is suspected and always
This research presents limitations on the reduced
when wet, loose, dirty, or with compromised integrity. It
size of the samples, which allowed only the analysis of
is important to protect the insertion site with plastic when
the data by descriptive statistics. On the other hand, the
showering with a dressing that is not waterproof
. It
results provide a basis for raising awareness about the
should be pointed out that in this study the dressing was
importance of following safe practices when providing
waterproof.
care for patients with intravenous devices. One result
(8,10)
In the etiology of hospital infections, the presence
could be the instigation of the development of future
of resistant strains has had an impact on morbidity,
clinical research concerned mainly with the relationship
mortality, and costs, reaching proportions that are
among: duration of use of peripheral venous catheters,
very worrisome
. The participation of S. aureus
sensitivity profiles, genetic similarity among the various
resistant to methicillin and of gram-negative bacilli
sample collection locations (3WSCS external surfaces
(3,17)
www.eerp.usp.br/rlae
7
Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E. and lumens, dressing, and insertion sites), and the
5. Folgori L, Bernaschi P, Piga S, Carletti M, Cunha
biofilm formation on the devices.
FP, Lara PH, et al. Healthcare-associated Infections in Pediatric and Neonatal Intensive Care Units: Impact of
Conclusion
Underlying Risk Factors and Antimicrobial Resistance on 30-Day Case-Fatality in Italy and Brazil. Infect
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Corresponding Author: Evandro Watanabe Universidade de São Paulo. Faculdade de Odontologia de Ribeirão Preto Av. do Café, s/n Bairro: Monte Alegre CEP: 14040-904, Ribeirão Preto, SP, Brasil E-mail: [email protected]
Copyright © 2017 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons (CC BY). This license lets others distribute, remix, tweak, and build upon your work, even commercially, as long as they credit you for the original creation. This is the most accommodating of licenses offered. Recommended for maximum dissemination and use of licensed materials.
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Rev. Latino-Am. Enfermagem 2017;25:e2887 DOI: 10.1590/1518-8345.1528.2887
www.eerp.usp.br/rlae
Microbiological testing of devices used in maintaining peripheral venous catheters1 Fernanda de Paula Rossini2 Denise de Andrade3 Lissandra Chaves de Sousa Santos4 Adriano Menis Ferreira5 Caroline Tieppo6 Evandro Watanabe7
Objective: to evaluate the use of peripheral venous catheters based on microbiological analysis of devices (dressing and three-way stopcocks) and thus contribute to the prevention and infection control. Methods: this was a prospective study of microbiological analysis of 30 three-way stopcocks (external surfaces and lumens) and 30 dressing used in maintaining the peripheral venous catheters of hospitalized adult patients. Results: all external surfaces, 40% of lumens, and 86.7% of dressing presented bacterial growth. The main species isolated in the lumen were 50% coagulase-negative Staphylococcus, 14.3% Staphylococcus aureus, and 14.3% Pseudomonas aeruginosa. Fifty nine percent of multidrug-resistant bacteria were isolated of the three-way stopcocks, 42% of the lumens, and 44% of the dressing with a predominance of coagulase-negative Staphylococcus resistant to methicillin. Besides, 18% gram-negative bacteria with resistance to carbapenems were identified from multidrug-resistant bacteria on the external surfaces of the three-way stopcocks. Conclusion: it is important to emphasize the isolation of coagulase-negative Staphylococcus and gram-negative bacteria resistant to methicillin and carbapenems in samples of devices, respectively, which reinforces the importance of nursing care in the maintenance of the biologically safe environment as well as prevention and infection control practices. Descriptors: Cross Infection; Vascular Access Devices; Catheters; Contamination; Bacteria; Drug Resistance, Microbial.
1
Paper extracted from Doctoral Dissertation “Residence time of the peripheral venous catheter and the bacterial growth in catheter and connector: subsidies for prevention of adverse events”, presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
2
PhD, RN, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
3
PhD, Associate Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
4
Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
5 6
PhD, Associate Professor, Universidade Federal do Mato Grosso do Sul, Três Lagoas, MS, Brazil.
Pharmacy-Biochemistry, Hospital Regional do Mato Grosso do Sul, Campo Grande, MS, Brasil.
7
PhD, Professor, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil.
How to cite this article Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E. Microbiological testing of devices used in maintaining peripheral venous catheters. Rev. Latino-Am. Enfermagem. 2017;25:e2887. [Access ___ __ ____]; Available in: ____________________. DOI: http://dx.doi.org/10.1590/1518-8345.1528.2887. URL
month day year
2
Rev. Latino-Am. Enfermagem 2017;25:e2887.
Introduction
3WSCs) used in peripheral venous access and thus, contribute to the prevention and control of infection.
Health
care
in
the
hospital
environment
is
constantly challenged by infections, which result in
Methods
increases in morbidity and mortality, length of stay, and costs, especially considering the consumption of antibiotics and laboratory tests. Given the proportions, these infections represent one of the largest public health problems, which is aggravated by the presence of resistant strains, since they challenge scientific and
technological
advances
the
attention
professionals,
of
and
therefore
catch
researchers,
and
organizations looking for effective prevention and
This is a microbiological clinical study done on the 3WSCs and dressing used in the maintenance of peripheral venous catheters (PVC) type abbocath used in hospitalized patients. Samples from the devices were collected for adult patients admitted to the medical and neurological clinical
specialty
of
a
public
university
hospital
inpatient for highly complex clinical emergency care. For 60 devices (30 dressing and 30 3WSCs), 90
control measures(1-3). Risk factors for infection is an indicator that deserves careful analysis and elucidation in the management of aseptic techniques. This analysis represents a challenge, given variability of risks and diversity of behaviors and recommendations. In this sense, the need emerges to objectively identify the possible risks of contamination
microbiological processes were carried out, 30 from the external surfaces, 30 from the lumens of the 3WSCs, and 30 from the dressing. The devices analyzed were collected after discontinuing use of the intravenous devices (due to doctor’s orders, obstruction, infiltration, the presence of classic phlebitis signs of pain, edema, hyperthermia, and local hyperemia), or in cases where
and colonization(4-5). The use of intravascular catheters constitutes a vital strategy for clinical practice and effectiveness of treatments(6-8). It is worth mentioning that peripheral venipuncture is not free of complications, since it is an invasive procedure of high frequency done most of the time in a hospital setting, which is a place that presents risks of contamination and colonization, and which requires appropriate conduct in care of catheters. The maintenance of peripheral venous catheters is a complex topic and requires following a number of technical aseptic conformities and operational principles with a view toward safety and the prevention and control
there was a need to change the dressing of the access considering the conditions of integrity and humidity. The removal of these devices from the patients was done exclusively by nurses working in the unit. We believe that removal according to hospital routine preserved the microbiological conditions of the real situation of hospital care. Any type of contamination was avoided during the removal and transfer of the samples to their sterile packaging. The area of the dressing in contact with the catheter insertion site was marked externally to show where the microbiological collection should be made. Furthermore, information was collected as to the
of infection. The incidence of phlebitis and infections associated
date of the peripheral venipuncture that was on the
with peripheral venous catheters is relatively low, but
dressing and description of the general conditions in
the possibility of underestimation of data should be
terms of dirtiness or presence of blood (evaluation of
pointed out, especially considering the high frequency
the macroscopic condition of the dressing). The research
with which this procedure is done in daily routine health
was conducted with the approval of the Research Ethic
care.
Committee (37194214.1.0000.5393).
Catheter-related
bacterial
infections
prolong
hospitalization and increase the cost of treatment, besides presenting attributable mortality rates in the range between 10% to 25%(6,9).
Inclusion criteria The evaluation included 3WSCs used in maintaining
According to these questions: Is it possible to
the PVC and sterile dressing made of soft fabric backed
isolate bacteria from samples of devices (dressing and
with rayon and polyester with hypoallergenic acrylate
three-way stopcocks - 3WSCs) used in peripheral venous
adhesive, water-resistant, non-owcclusive, and made of
access? What is the prevalence and sensitivity profile
hypoallergenic transparent film with vapor permeability.
of the isolated bacteria? Moreover, are these bacteria resistant to carbapenems?
Microbiological processing
Therefore, this research attempts to evaluate the
The collection of biological material from the
microbiological conditions of devices (dressing and
dressing was done by friction on the inner surface www.eerp.usp.br/rlae
3
Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E. with a swab moistened with saline solution, which was
The length of stay of the PVC ranged from 2 to 8
in contact with the catheter insertion site (previously
days: 36.7% of the samples indicated that the venous
defined area) for 30 seconds and in three directions.
catheterization had been done three days ago (72 hours)
Then the swab was transferred to a sterile test tube
and 26.7% four days ago (96 hours). The mean and
(25 mm x 125 mm) containing 20 mL of Tryptic Soy
median of the length of stay of the PVC was 3.75 days and
Broth (TSB). For the culture from the 3WSCS’s lumen,
three days respectively with a standard deviation of 1.48.
a syringe and sterile gloves were used to carry out a
Additionally, when the presence or absence of
flush of 10 mL of TSB through each of the two routes of
macroscopic dirtiness on the devices was analyzed, such
the 3WSCS into a sterile test tube (25 x 125 mm) with
as the presence of blood with bacterial growth in a TSB
glass beads. For the culture of the external surface the
culture medium, it was observed that 46.6% of these
3WSCS was flushed with the routes closed into a sterile
samples were not considered dirty but had a positive
vial with 200 mL of TSB.
culture for bacterial growth, 28% were considered dirty
After these procedures, homogenization was carried
and showed positive results, 16.7% were considered
out on the samples using an AP-56 tube shaker (Phoenix,
dirty but were not positive, and 7.8% were not
Brazil) during 1 minute and then the samples were
considered dirty and also were not positive.
incubated (Quimis, Brazil) at 37°C for 24 hours up to 14
As for the microbiological evaluation of the devices
days (sterility test). The initial microbiological analyses
(dressing, lumen, and the external surface of the
were performed in a Class II Biological Safety Cabin -
3WSCs), 76 bacteria were isolated from the total of 68
Model Bio Seg 12 (VECO Group, Brazil) in the microbiology
positive samples for bacterial growth with the main ones
laboratory. After incubation, the samples were seeded on
being as follows: coagulase-negative Staphylococcus at
Petri plates (15 x 90 mm) with selective culture media
51.3%, Staphylococcus aureus at 12%, Pseudomonas
(Mannitol, MacConkey, and Cetrimide) and processed in
aeruginosa at 9.2%, and Klebsiella pneumoniae at 9.2%
a VITEK
(Figure 1).
®
2 Compact automated system (Biomérieux,
France) for bacterial identification and sensitivity profile.
Results
samples of the dressing, lumen, and external 3WSCS
Of the total of 90 microbiological analyses, the samples from the lumen of the 3WSCs had growth positive levels of 40% in the TSB culture medium. The samples from the dressing showed 86.7% of contamination and the external surface of the 3WSCs 100% (Table 1).
lumens and external surfaces of the three-way stopcocks used in peripheral venous catheters. Ribeirão Preto, SP, Brazil, 2015 Bacterial Growth
Culture Medium (Tryptic Soy Broth)
multi-resistant microorganisms, respectively. It should be pointed out that in some samples more than one bacterium was isolated. Of the total of resistant microorganisms isolated in the samples of the culture from the dressing, the Staphylococcus resistant to methicillin at 91% and Klebsiella pneumoniae resistant to carbapenems at 9% (Table 2). In the lumen of the 3WSCs (Table 3), the one that
stands
out
the
most
is
coagulase-negative
Staphylococcus resistant to methicillin at 100%.
n
%
26
86.7
samples from the external surface of the 3WSCs (Table 4), the three that stand out the most are coagulase-
Dressing
Present Absent
4
13.3
Three-way stopcocks lumen
Present
12
40.0
Absent
18
60.0
Three-way stopcocks external surfaces
Present
30
100
Absent
0
0
www.eerp.usp.br/rlae
surface, 44%, 35.7%, and 73.3% showed growth of
two that stand out the most are coagulase-negative
Table 1 - Evaluation of bacterial growth on dressing,
Devices
Regarding the evaluation of the profile of sensitivity to antibiotics of the bacteria isolated in the positive
Of the total of resistant bacteria isolated in the
negative Staphylococcus with a 72.7% prevalence, followed by 9% for Staphylococcus aureus resistant to methicillin, and 9% for Klebsiella pneumoniae resistant to carbapenems.
4
Rev. Latino-Am. Enfermagem 2017;25:e2887.
Figure 1 - Evaluation of bacteria distribution in the samples of dressing, lumens and external surfaces of the threeway stopcocks used in peripheral venous catheters. Ribeirão Preto, SP, Brazil, 2015 Table 2 - Evaluation of numerical and percentage distribution of bacteria in dressing used in peripheral venous catheters according to antibiotics sensitivity profile. Ribeirão Preto, SP, Brazil, 2015 Dressing Bacteria
Resistant (n=11)
Sensitive (n=14)
n
%
n
%
10*
91.0
3
21.4
Pseudomonas aeruginosa
0
0
3
21.4
Klebsiella pneumoniae
1
9.0
2
14.3
Staphylococcus aureus
0
0
2
14.3
Enterobacter cloacae
0
0
2
14.3
Proteus mirabilis
0
0
1
7.10
Leuconostoc mesenteroides
0
0
1
7.10
Coagulase-negative Staphylococcus
†
* Methicillin-resistant coagulase-negative Staphylococcus. † Carbapenem-resistant Klebsiella pneumoniae.
Table 3 - Evaluation of numerical and percentage distribution of bacteria in lumens of the three-way stopcocks used in peripheral venous catheters according to antibiotics sensitivity profile. Ribeirão Preto, SP, Brazil, 2015 3WSCs* lumen Bacteria
Resistant (n=5)
Sensitive (n=9)
n
%
n
%
Coagulase-negative Staphylococcus
5*
100
2
22.2
Staphylococcus aureus
0
0
2
22.2
Pseudomonas aeruginosa
0
0
2
22.2
Klebsiella pneumoniae
0
0
1
11.0
Proteus mirabilis
0
0
1
11.0
Enterococcus faecalis
0
0
1
11.0
* Methicillin-resistant coagulase-negative Staphylococcus.
Table 4 - Evaluation of numerical and percentage distribution of bacteria in external surfaces of the three-way stopcocks used in peripheral venous catheters according to antibiotics sensitivity profile. Ribeirão Preto, SP, Brazil, 2015 3WSCs* external surface Resistant (n=22)
Bacteria
Sensitive (n=15)
n
%
n
%
Coagulase-negative Staphylococcus
16*
72.7
3
20.0
Staphylococcus aureus
2*
9.0
3
20.0
(continue...) www.eerp.usp.br/rlae
5
Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E.
Table 4 - (continuation) 3WSCs* external surface Resistant (n=22)
Bacteria
Sensitive (n=15)
n
%
n
%
Klebsiella pneumoniae
2†
9.0
1
6.60
Pseudomonas aeruginosa
1†
4.5
1
6.60
Acinetobacter baumannii
1
4.5
1
6.60
Enterococcus faecalis
0
0
2
13.3
Citrobacter koseri
0
0
1
6.60
Proteus mirabilis
0
0
1
6.60
Providencia stuartii
0
0
1
6.60
Enterococcus faecium
0
0
1
6.60
†
* Methicillin-resistant (coagulase-negative Staphylococcus and Staphylococcus aureus). † Carbapenem-resistant (Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii).
Discussion
Pseudomonas aeruginosa (4.5%), and Acinetobacter baumannii (4.5%). Thus, it is important to emphasize
The use of intravascular catheters is one of the
that
good
aseptic
practices
should
be
carefully
important advances in medicine, but we should not be
adopted and enforced by the professionals who
oblivious to the risks inherent in their use, especially
handle the devices used in the maintenance of the
infectious events. Some factors that increase the risk
venous catheters in order to avoid contamination
of infection are use of the devices, insertion site, length
of the internal lumen and resultant bloodstream
of stay, skin preparation, and type and way of fastening
infections(8,10).
the dressing used(8-10). There is a further concern with
At the center of discussions of infection control in
the 3WSCs, because beyond being useful in peripheral
health services is the behavior of health professionals,
venous infusions, they also belong to the arsenal of
and it is mentioned as an important tool in the
venous extensions.
implementation of safe practices(1,13). But even though
The literature reveals a low risk of infection of the
measures to prevent and control bloodstream infection
bloodstream associated with the use of peripheral venous
are carefully established by guidelines, the reality of
catheters; however, we must consider its high use in
health care points to unsatisfactory levels of compliance
health care, a fact that has been changing this scenario(8).
by health professionals, especially for the practices of
On the other hand, one study(11) demonstrated that the
washing hands (10.7%) and disinfection of hubs and
number of bloodstream infections caused by peripheral
connectors (40.0%) prior to drug administration(10,14).
venous catheters and central venous catheters were
It should be noted that connections such as 3WSCs/
similar, and that the peripheral catheters inserted in the
hubs and infusion equipment are a common gateway
emergency department caused the largest number of
for
episodes.
connectors can result in bacterial contamination of the
microorganisms(15).
Inadequate
disinfection
of
The study evaluated the microbiota, the profile of
inner lumen of the catheter, resulting in the formation
sensitivity of the bacteria isolated from some devices
of biofilm and subsequent bloodstream infection(8).
(dressing, lumens, and external surfaces of the 3WSCS)
On the other hand, we cannot ignore the possibility
used in the maintenance of peripheral venous access,
that contamination of the catheter’s inner lumen may
the duration of use of the device, and the presence of
originate in the migration of bacteria inside the catheter
macroscopic dirtiness.
coming from the patient’s skin and migrating to the
In the study, microbial growth in the cultures from
the
external
of
the
3WSCs
catheter’s tip.
was
We consider the contamination rate in the lumen of
100%. Some investigators have speculated that the
the 3WSCs (40%) to be high and worrisome, especially
surface contamination of the 3WSCS occurs due to
by
environmental exposure, manipulation by nursing
Staphylococcus resistant to methicillin. In general, for
staff, contact with the patient’s microbiota and contact
hospitalized patients undergoing intravenous therapy, the
with the bed linen(8,12). Among the resistant bacterial
devices are frequently manipulated to administer drugs
species isolated from the 3WSCS surfaces, the main
at regular intervals; or as is the case with antibiotics,
ones were gram-negative bacteria with a resistance
every 6 hours; or analgesics and antipyretics in the case
to carbapenems such as Klebsiella pneumoniae (9%),
of pain or fever, among other drugs. This fact reinforces
www.eerp.usp.br/rlae
surfaces
resistant
bacteria
such
as
coagulase-negative
6
Rev. Latino-Am. Enfermagem 2017;25:e2887. the need for professionals to adopt safe practices when
resistant to carbapenems is increasingly frequent
administering drugs, including meticulous hand hygiene.
in episodes of bacteremia in critically ill patients(18).
Thus, we highlight the importance of disinfecting the
Thus, another challenging result involved evaluating
hubs and hand hygiene (HH) before and after handling
multidrug-resistant strains and strains with resistance
the devices, along with other procedures that impede
to
contamination of the lumen on the 3WSCs. So failure to
peripheral venous catheters. For decades, the world
observe aseptic principles contributes to contaminating
has witnessed a proliferation of microbes with antibiotic
the devices.
resistance, which implies the acquisition of genes
carbapenems
in
the
maintenance
devices
of
HH is the simplest and least expensive individual
that determine resistance to the point of becoming
measure to prevent the spread of healthcare-related
refractory to virtually all antibiotics, leaving researchers
infections(6). However, it was not our objective in this
and health professionals in a bleak environment with
study, to determine the frequency of this practice when
no therapeutic options. Undoubtedly, one of the most
handling the device.
important factors involved is the wide use of antibiotics
Furthermore, the lids should be used when closing
in outside of hospitals.
the 3WSCs, which should be strictly maintained in order
Another important point is that in health institutions,
to preserve their sterile condition. However, in the real
the spread of resistant strains is also facilitated by
situation of providing care, actions can be taken that
noncompliance
contaminate the inside of the lids, such as leaving them
as washing hands, use of protective barriers, and
on trays or other surfaces with the inner side facing down
decontamination of equipment, among other practices(19).
with
basic
recommendations
such
and then reusing them, when in reality the 3WSCs lids
Although there is evidence in literature of low risk
should be discarded with every handling of the device
of local infection of the bloodstream associated with
for infusion(10).
peripheral venous catheters, this situation is changing(9).
Furthermore, we observed that 86.7% of the
For this reason, one should not miss the importance of
culture from the dressing in TSB were positive, which
this issue, especially considering its gravity, the etiology
is contrary to our hypothesis. It was speculated that it
of the microbial species, and the main predisposing
would be 100%, since dressing are in direct contact with
factors(20-21). The success of the fight against infection
the patient’s skin and their endogenous microbiota, and
depends not only on accurate diagnosis, but also, and
mainly because the sample is collected at the catheter’s
in the same proportion, on improvement of conditions
insertion(11).
in terms of infrastructure and human resources. As
The risk became alarming when profile of sensitivity
mentioned before, the performance and attitudes of
to antibiotics of the species were analyzed; coagulase-
health professionals is relevant. It is necessary to begin
negative
methicillin
to build an educational system that promotes knowledge,
was at 91% and Klebsiella pneumoniae resistant to
Staphylococcus
resistant
to
skills, and attitudes that are converted into legitimized
carbapenems was at 9%. It should be noted that perhaps
critical and reflective professional practice. Some of
four (13.3%) of the negative cultures were associated
these issues are more acute in countries facing crises
with the technique of swab collection at just one point
in basic conditions of infrastructure, which includes the
(ostium of insertion), duration of use of the dressing,
training of human resources.
humidity control, and best aseptic practices
.
The results of the present study encourage a
(16)
The purpose of the dressing is to protect the
number of reflections, and one is the need to perform
puncture site and minimize the possibility of infection
essential prospective surveillance to prevent and control
through the interface between the surface of the
hospital infections, thus favoring decision-making based
catheter and the skin. The dressing should be replaced
on situations of real care.
immediately if contamination is suspected and always
This research presents limitations on the reduced
when wet, loose, dirty, or with compromised integrity. It
size of the samples, which allowed only the analysis of
is important to protect the insertion site with plastic when
the data by descriptive statistics. On the other hand, the
showering with a dressing that is not waterproof
. It
results provide a basis for raising awareness about the
should be pointed out that in this study the dressing was
importance of following safe practices when providing
waterproof.
care for patients with intravenous devices. One result
(8,10)
In the etiology of hospital infections, the presence
could be the instigation of the development of future
of resistant strains has had an impact on morbidity,
clinical research concerned mainly with the relationship
mortality, and costs, reaching proportions that are
among: duration of use of peripheral venous catheters,
very worrisome
. The participation of S. aureus
sensitivity profiles, genetic similarity among the various
resistant to methicillin and of gram-negative bacilli
sample collection locations (3WSCS external surfaces
(3,17)
www.eerp.usp.br/rlae
7
Rossini FP, Andrade D, Santos LCS, Ferreira AM, Tieppo C, Watanabe E. and lumens, dressing, and insertion sites), and the
5. Folgori L, Bernaschi P, Piga S, Carletti M, Cunha
biofilm formation on the devices.
FP, Lara PH, et al. Healthcare-associated Infections in Pediatric and Neonatal Intensive Care Units: Impact of
Conclusion
Underlying Risk Factors and Antimicrobial Resistance on 30-Day Case-Fatality in Italy and Brazil. Infect
In general, the results are alarming because the
Control Hosp Epidemiol. [Internet]. 2016 [Access Aug
contamination by antimicrobial resistant bacteria was
29,
identified, and coagulase-negative Staphylococcus re-
cambridge.org/action/displayAbstract?fromPage=onli
sistant to methicillin was predominant in samples from
ne&aid=10467817&fileId=S0899823X16001859.
dressing, lumen and the external surface of 3WSCS. Moreover, it is important to emphasize the isolation of gram-negative bacteria resistant to carbapenems on
2016];11:1-8.
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Corresponding Author: Evandro Watanabe Universidade de São Paulo. Faculdade de Odontologia de Ribeirão Preto Av. do Café, s/n Bairro: Monte Alegre CEP: 14040-904, Ribeirão Preto, SP, Brasil E-mail: [email protected]
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